Provider First Line Business Practice Location Address:
206 S JEFFERSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IOLA
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66749-3353
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-365-3404
Provider Business Practice Location Address Fax Number:
620-365-6434
Provider Enumeration Date:
12/28/2006